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Antidepressants may help men with premature ejaculation

The drugs can delay premature ejaculation

Last updated: April 2011

Most men don't seek medical help for this problem—partially because they may be embarrassed or perhaps because they are unaware that effective treatments are available. But premature ejaculation (PE) is a common male sexual disorder that often affects the sexual satisfaction of the man, his partner or both. It may also diminish his self-confidence and cause him anxiety and depression.

At the same time, many men have concerns about the condition even when their ejaculation time falls in the normal range of around 3 to 6 minutes. While the time varies, a study of about 500 men found that the median time was 5.4 minutes. (That figure varied with age, from 6.5 minutes among men 18 to 30 to 4.3 minutes for men older than 51.) Moreover, many men experience variations within the normal range.

In contrast, PE occurs when a man always (or nearly always) experiences ejaculation within a minute or less during sexual activity. It can also be defined as the inability to regularly delay ejaculation and reacting with distress or avoidance of sexual intimacy. Premature ejaculation may be "lifelong," beginning when the man first becomes sexually active and occurring with nearly every partner. Or it may be "acquired," occurring after having normal ejaculation times up until then.

Traditionally, the only options for men with PE were psychotherapy and behavioral therapy. But some men explore medical options, including low doses of the antidepressants known as selective serotonin reuptake inhibitors (SSRIs). These drugs are FDA-approved for the treatment of depression, and some are approved for other health conditions. But others have increasingly become first-choice drugs—although used "off-label" for PE—which may be related, in part, to lower levels of serotonin, a chemical in the brain that has a delaying effect in ejaculation. SSRIs increase the production of serotonin, and a side effect, first noted in the treatment of depression, is prolonging the time it takes to reach ejaculation. (Doctors can legally prescribe any medication for conditions other than those approved by the FDA.)

"Most men with premature ejaculation respond to daily treatment with SSRIs, and some respond really well," says Ira Sharlip, M.D., a clinical professor of urology at the University of California, San Francisco, and a spokesman for the American Urological Association. "But there are significant side effects that, while not harmful, are unpleasant for the patients who experience them."

What is the evidence?

Researchers conducted a meta-analysis of studies examining SSRIs and clomipramine—an older type of antidepressant—in the treatment of PE. They found that daily use of clomipramine (Anafranil, generic) and the SSRIs paroxetine (Paxil and generic), sertraline (Zoloft, generic), and fluoxetine (Prozac, generic) delayed ejaculation, with paroxetine having the strongest effect.

Most of the studies did not meet scientific standards, so a narrower analysis focused on eight randomized, placebo-controlled trials that included a stopwatch measurement of time to ejaculation. It found the following order of average effectiveness in increasing time to ejaculation was: paroxetine (an 8.8-fold increase); clomipramine (4.6-fold increase); sertraline (4.1-fold increase); and fluoxetine (3.9-fold increase). Research suggests that clomipramine might cause more bothersome side effects than SSRIs, which could limit its use.

Other studies have investigated the "on-demand" use of antidepressants for PE, in which men take the drug only before sexual activity instead of taking it daily. Although the study methods used in the research can't be compared, evidence suggests that on-demand use doesn't strongly delay ejaculation as much as daily use of antidepressants. In addition, the drug must be taken about 3 to 5 hours before intercourse, which can dampen spontaneity. While on-demand treatment continues to be the subject of debate, Sharlip says most of his patients want to try it because it reduces the risk of side effects.

The American Urological Association and the European Association of Urology recommend the use of certain SSRI medications to treat men with PE. However, as noted in the AUA guidelines, safety should be the primary concern.

What are the risks and warnings?

For daily use of antidepressants, since lower doses are used in the treatment of premature ejaculation, the frequency and severity of side effects might be lower. Common reactions that are usually mild and gradually disappear within a couple weeks include diarrhea, dry mouth, drowsiness, fatigue, nausea, perspiration, and yawning. The following problems might also occur:

Suicidal behavior. A black-box warning—the FDA's most serious label alert—states that SSRIs have been reported to increase the risk of suicidal thinking and behavior in children, adolescents, and young adults with major depression and other psychiatric disorders. The incidence of suicide is lower among those older than 25 with major depression. But no matter what your age, if you're thinking about hurting yourself, talk with your doctor.
Serotonin syndrome

This life-threatening reaction is rare but happens most often when two serotonin-boosting drugs are used at the same time, causing agitation, coma, changes in heart rate and blood pressure, hallucinations, loss of coordination, and vomiting. Avoid the use of older antidepressants such as monoamine oxidase inhibitors, triptan medications for migraine headaches such as almotriptan (Axert) and tramadol (Ultram), and tryptophan supplements. Some other drugs that raise serotonin levels include:

St. John's wort and other herbal products

Over-the-counter medicine that contains dextromethorphan, used for coughs

Sexual side effects. Decreased desire and problems reaching orgasm might occur with SSRIs, but those side effects are reported less frequently in men taking the drugs for PE. Talk with your physician about diminished libido or other sexual problems that appear during treatment.

Low sodium. People who take diuretics might be at the greatest risk for this problem. Symptoms include confusion, headaches, memory and concentration impairment, unsteadiness, and weakness.

Weight gain. This might increase the risk of diabetes.

Abnormal bleeding. The risk is uncommon but higher in people taking blood thinners or nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen (Advil).

Prolonged erection. If this rare but serious reaction occurs, discontinue using the drug and call your doctor.

What other measures can you try?

Rule out other conditions. Your doctor should ask about your medical and sexual history before prescribing a drug for PE. A physical exam might be necessary in the initial assessment of the condition, which is occasionally caused by inflammation of the prostate or an overactive thyroid. The underlying condition should be treated first.

Consider a topical anesthetic. It can be an effective alternative treatment for PE. Lidocaine-prilocaine cream (Emla) is applied to the penis 20 to 30 minutes before intercourse. A condom should be worn to avoid transferring the product to a partner.

Use a condom. It might reduce stimulation and thus delay ejaculation for some men.

Try relationship counseling and behavioral approaches. This includes the stop-and-start technique, the squeeze method, and thought distraction. These can be used on their own or in combination with drug treatment.

Bottom line. Studies have found that daily treatment with certain SSRIs, especially paroxetine, can delay ejaculation for men with PE. An on-demand regimen has been found to be less effective but can pose fewer side effects. Our advice: Talk with your doctor about all available drug and nondrug treatments for PE, and consider SSRIs only after the risks and benefits have been thoroughly explained to you.

This off-label drug use report is made possible through a collaboration between Consumer Reports Best Buy Drugs and the American Society of Health-System Pharmacists. This is the 23rd in a series based on professional reports prepared by ASHP.

These materials were made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by a multistate settlement of consumer fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).